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Waste Tire Sway & Inspection Report Inspection Report Number <br /> `•&���' State of California <br /> CWMB 181 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 11 1127503 <br /> Part A- Survey- BLUE OR BLACK INK-PEN <br /> Business Profile Inspection Details <br /> TPID- , . Inspection Type (Fill one) <br /> Site Suffix: ` ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: � , <br /> -�-1� (,� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> / �1,� 1 p y Inspector <br /> oo i CJYl�l C� <br /> Physical Address - l- <br /> ILW4 G. l l 6`�� <br /> Inspection Date / <br /> a,5c?o5 <br /> Time In Time Out <br /> Business Rep Title %� OAML� - <br /> V Z l/ QPM c 1 C1 � O PM <br /> Operational StatusTire Type Business Role storage Type <br /> Tire Count (Whole/PTE) r�, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®.Active ® Passenger ® Generator ®Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFbRCEMEl �S �►TUSG� � ' <br /> WAULING AN[)#MANIFEST RQUIREMENTS <br /> 01 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires � asP.e <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I � Q. <br /> Q Q PRC§42956-Registration/Decal in Vehicle - h <br /> � g r <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements 4 �a <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days �E 1 <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years g1 ; <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> e. , <br /> Q Q Other: § ., � <br /> Comments I^ <br /> ylis <br /> Inspection Form Included: QII <br /> Comments Included: Q --- <br /> Bus' ss ep'sSign ture - Phone Number I - c Signature Phone Number <br /> INSTRUCTIONS ON ACK 1 orr ct co�rcg `� , <br /> Pi, <br /> 62081 <br /> White Cop :CI Yellow Copy:Operator Pink Copy:LEA <br />